Pulmonology Flashcards
path in asthma
reversible inflammation and bronchoconstriction
pt in asthma
SOB, wheezing, hyper resonant, prolonged expiration, exposure to trigger (cold air, allergens)
CBC = eosinophilia; ‘nasal polyps’
dx of asthma
PFTs - FEV1/FVC decreased - reversible with bronchodilators - inducible with methacholine skin test = identify triggers
tx of asthma
ß-agonists - short-acting, long-acting steroids - inhaled corticosteroids, oral prednisone stabilizers - nedocromil, cromolyn - leukotriene antagonists
f/u asthma
avoid triggers
chronic asthma treatment I
SABA
chronic asthma treatment II
SABA + ICS (LTA = ICS)
chronic asthma treatment III
SABA + ICS + LABA
chronic asthma treatment IV
SABA + increase ICS + LABA
refractory asthma treatment
oral prednisone
asthma drugs - SABA
albuterol
asthma drugs - LABA
formoterol, salmetrol
asthma drugs - ICS
beclomethasone, budesonide, fluticasone, mometasone
asthma drugs - steroids
prednisone (oral)
asthma exacerbation path
exposure to trigger
asthma exacerbation pt
exposure to trigger = wheezing, dyspnea, prolonged exhalation
CBC = eosinophilia
nasal polyps
asthma exacerbation dx
clinical
peak flow
asthma exacerbation tx
IV methylprednisolone
albuterol + ipratroprium
steroid taper
asthma exacerbation f/u
racemic epinephrine
magnesium
stops wheezing or CO2 rising -> intubate
lung cancer path
smoking, toxic exposure
lung cancer pt
weight loss, hemoptysis, dyspnea, pleural effusion (tap effusion first)
lung cancer dx
1st: cxr
then: CT
best: biopsy
- percutaneous if peripheral
- endoscopic ultrasound if proximal
- VATS if in the middle
- lobectomy okay too
lung cancer tx
diagnose, stage
PFTs (can they tolerate surgerY?)
surgery vs. chemo
lung cancer f/u
annual low-dose CT scan…cancer screen
- smoker within 15yrs
- 55-80y/o
- > 30 pack-year history
small cell lung cancer path
smoking
small cell lung cancer pt
sentral mass (central) paraneoplastic syndromes - SIADH = HypoNa - ACTH = Cushing's
small cell lung cancer dx
bronch/EUS
small cell lung cancer tx
chemo
squamous cell lung cancer path
smoking
squamous cell lung cancer pt
sentral mass (central) paraneoplastic syndromes - PTH-rp = HyperCa
squamous cell lung cancer dx
bronch/EUS
squamous cell lung cancer tx
resection
chemo, radiation
adenocarcinoma path
asbestosis
cancer NON smokers get
adenocarcinoma pt
peripheral mass
pleural plaques
adenocarcinoma dx
percutaneous biopsy
adenocarcinoma tx
chemo/rads
carcinoid tumor path
serotonin
carcinoid tumor pt
wheezing, flushing, diarrhea
carcinoid tumor dx
5-HIAA in the urine
carcinoid tumor tx
resection
pleural effusion path
transudate: ‘fluid’
- increase hydrostatic = CHF
- decrease oncotic = cirrhosis, nephrosis
exudative: ‘stuff’
- increase permeability = TB, cancer, PNA
pleural effusion pt
exertional dyspnea, orthopnea,
incidentally found on xray
pleural effusion dx
1st: cxr
then: decubitus cxr (or ultrasound)
then: thoracentesis (not loculated)
OR
thoracotomy (loculated)
OR
thoracotomy (empyema)
Best: biopsy, gram stain, cytology
pleural effusion tx
if CHF, do NOT tap, just diuresis
if no CHF, tap, then treat accordingly to the underlying diagnosis
thoracentesis
needle in the chest
thoracostomy
chest tube in chest
thoracotomy
hole cut in the chest
Light’s Criteria
signifies exudate if:
- LDH > 200
- LDH fluid : LDH serum > 0.6 (high LDH)
- TP fluid : TP serum >0.5 (high protein)
pleural effusion work up: cell count with diff
infection
pleural effusion work up: gram stain
infection
pleural effusion work up: culture
infection
pleural effusion work up: AFB smear
TB
pleural effusion work up: adenosine deaminase
TB
pleural effusion work up: cytology
cancer
pleural effusion work up: Total protein (TP)
light’s criteria
pleural effusion work up: LDH
light’s
pleural effusion work up: RBC
hemothorax
pleural effusion work up: amylase
chylothorax
pleural effusion work up: pH, glucose
other
DVT path
virchow’s triad:
- endothelial injury
- venous stasis
- hypercoaguability
DVT pt
unilateral leg swollen than the other >2cm
pain, erythema, swelling
DVT dx
ultrasound
DVT tx
anticoagulation (LMWH->warfarin)
PE path
DVT embolisms to lung
PE pt
wedge infarct = hemoptysis, dyspnea pulmonary HTN = heart strain ischemia = pleuritic chest pain V/Q mismatch = hypoxemia and dyspnea tachycardia, tachypnea, hypoxia, hypocapnia
PE dx
1st: D-dimer rules out disease (clinic)
Best: spiral CT (CT chest IV contrast)
Alt: V/Q scan if creatninine compromised
PE tx
IVF, O2, anticoagulation
- heparin to warfarin bridge
- 5d LMWH or therapeutic INR 2-3, whichever is longer
- tPa if massive
- IVC filter ONLY if anticoagulation is contraindicated
PE f/u
ABG: low O2, Low CO2, high pH
EKG: S1Q3T3
cxr: negative
Well’s criteria
Well’s Criteria
ZOMFG IDK = +3 DVT = +3 HR > 100 = +1.5 Immobilization (leg fx, travel) = +1.5 surgery within 4 weeks = +1.5 hx of DVT or PE = +1.5 hemoptysis = +1 malignancy = +1
Well’s Criteria interpretation
If Score <2 & D-Dimer, VQ okay: low probability
if score 2-6 & VQ useless: med probability
if score >6 & V/Q ok: high probability
When to do a CT scan based on Well’s criteria
Score = 4 -> don’t do it
score >4 -> do it
COPD time
emphysema and bronchitis
genetics and smoking
COPD pt - pink puffer
pink puffer = emphysema = trapped air
- hyperresonant
- increase AP diameter, flattened diaphragm
- pursed lips, prolonged expiration
- CO2 retainer
COPD pt - blue bloater
blue boater = bronchitis = hypoxia
- cyanotic
- pulmonary HTN
- right heart failure
- hepatosplenomegaly
- peripheral edema
COPD dx
PFTs: decrease FEV1/FVC … irreversible
cxr can show flattened diaphragms
COPD tx
Corticosteroids = ICS -> oral prednisone Oxygen = PaO2 <55 or SpO2 < 88% Prevention = smoking cessation, vaccines Dilators = bronchodilators, ipratropium Experimental = don't worry bout it Rehab = exercise capacity increases
Escalation of therapy for COPD
SABA SABA + tiotropium SABA + tiotropium + LABA SABA + tiotropium + LABA/ICS SABA + tiotropium + LABA/ICS + PDE-4i ...add oral steroids
COPD exacerbation path
infectious (viral or bacterial)
COPD exacerbation pt
cough, SOB, productive sputum
wheezing
CO2 retention
COPD exacerbation dx
1st: cxr (rule out pneumonia)
ABG = CO2 retention
COPD exacerbation tx
CO2 = BiPAP
albuterol and ipratropium
oral or IV steroids
abx = doxycycline or azithromycin
COPD exacerbation f/u
intubate if CO2 rises
ARDS path
non-cariogenic pulmonary edema
ARDS pt
TRALI, gram negative rods, near-drowning
bilateral fluffy infiltrates on cxr
pulmonary edema
ARDS dx
ARDS criteria
- P/F ratio <200
- echo, BNP, PCWP normal
- pulmonary edema
ARDS tx
intubation PEEP low TV... 6cc/kg IBW oxygenation paralysis
ARDS f/u
fix underlying disease
CHF vs. ARDS: PCWP
ARDS = decreased CHF = increased
CHF vs. ARDS: LV function
ARDS = increased CHF = decreased
CHF vs. ARDS: cxr
ARDS = fluffy CHF = fluffy
CHF vs. ARDS: 2d echo
ARDS = normal CHF = LV dysfunction
CHF vs. ARDS: BNP
ARDS = decreased CHF = increased
diffuse paranchymal lung disease (DPLD) or interstitial lung disease (ILD) path
variable
DPLD pt
chronic, insidious onset dry cough hypoxemia restrictive picture dry crackles
DPLD dx
cxr
high resolution CT
bx = VATS
DPLD tx
anti-inflammatories
- DMARDs
- biologics
- steroids
DPLD f/u
O2 supplementation if SpO2 <88%
sarcoid path
autoimmune, infiltrating disease
sarcoid pt
young, African American woman
bilateral hilar lymphadenopathy
Erythema nodosum
sarcoid dx
1st: cxr = bilateral hilar lymphadenopathy
then: PFTs = restrictive
best: biopsy = noncaseating granuloma
sarcoid tx
prednisone
sarcoid other
hypercalcemia .. vit D from granuloma
bradycardia/block = infiltrating heart
restrictive cardiomyopathy
asbestos path
inhaled, non-degradable material
asbestos pt
construction worker
shipyard industry
lung cancer or interstitial lung disease
asbestos dx
1st: cxr = pleural plaques
best: biopsy = barbell bodies
asbestos tx
smoking cessation
asbestos f/u
high risk for adenocarcinoma of lung
pneumoconiosis
heavy metal
ground-glass opacities
asbestosis
shipyards, construction, demolition
pleural plaque
silicosis
rock dust, sand blasting
coal miner’s
coal
Caplan Syndrome
hypersensitivity pneumonitis
noncaseating granulomas
pigeon feathers
actinomyces
special considerations: asbestosis
exposure: shipyards, construction
correlation: cancer
special considerations: berylliosis
exposure: aeronautics, nuclear
special considerations: silicosis
exposure: sand blasting, rock quarries
correlation: TB
special considerations: HE
histoplasmosis
exposure: birds, work only
correlation: get away from birds, get away from work